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Urinary tract infection (UTI) is frequent in the first year of life with bowel and bladder dysfunction, GU tract abnormalities, neurogenic bladder, and the intact prepuce conveying an increased risk. Urine culture is the gold standard for diagnosis. Antibiotics are tailored to resistance patterns. Guidelines have been established to direct the evaluation for GU anomalies but differ significantly. Bladder and bowel dysfunction is important to screen for and treat in potty-trained patients. Circumcised boys with febrile UTIs are more likely to have anatomic abnormalities than uncircumcised boys., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The conventional approach to managing a newborn with cloacal exstrophy typically includes separating the cecal plate from between the two hemibladders, tubularizing it to be included in the fecal stream, creating an end colostomy, and bringing the two bladder halves together. This study introduces an alternative approach wherein the cecal plate is retained in its original position and designated for future use as an autoaugment of the bladder. Four cases of cloacal exstrophy cases managed between November 2019 and February 2024 are described, with surgical approach and postoperative outcomes reported. Two patients who underwent traditional reconstruction experienced bacterial overgrowth attributed to stasis in the cecal plate, which manifested in increased ostomy output and feeding intolerance. Treatment in these two cases was to remove the cecum from the fecal stream and use it instead for a bladder augment. Learning from these cases, the third and fourth newborn's approach involved retaining the cecum in situ for autoaugmentation of the bladder and performing an ileal to hindgut anastomosis. No postoperative acidosis occurred in these patients. The alternative approach to the newborn management of cloacal exstrophy whereby the cecal plate is left in situ can decrease stasis and postoperative bacterial overgrowth. It allows for an autoaugmentation of the bladder and is technically easier than the traditional rescue of the cecal plate from within the two hemibladders., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. ( https://creativecommons.org/licenses/by/4.0/ ).)

Introduction: Hydronephrosis grading systems risk stratify patients with potential ureteropelvic junction obstruction, but only some criteria are measured objectively. Most notably, there is no consensus definition of renal parenchymal thinning., Objectives: The objective of this study was to assess the association between sonographic measures of renal length, renal pelvic diameter, and renal parenchymal thickness and the outcomes of a)renal hypofunction(differential renal function{DRF} <40%) and b)high-risk renal drainage(T1/2 > 40 min)., Study Design: An institutional database of patients who had diuretic renograms(DR) for unilateral hydronephrosis was reviewed. Only infants with Society for Fetal Urology(SFU) grades 3/4 hydronephrosis without hydroureter on postnatal sonogram and had a DR within 120 days were included. The following measurement variables were analyzed: anterior posterior renal pelvic diameter(APRPD), renal length(RL), renal parenchymal thickness(PT), minimal renal parenchymal thickness(MPT = shortest distance from mid-pole calyx to parenchymal edge), and renal pyramidal thickness(PyrT). RL, PT, MPT, PyrT measurements were expressed as ratios (hydronephrotic kidney/contralateral kidney). Multivariate logistic regression was performed for each outcome by comparing three separate renal measurement models. Model 1: RLR, APRPD, MPTR; Model 2: RLR, APRPD, PTR, Model 3: RLR, APRPD, PyrTR. Individual performance of variables from the best performing model were assessed via ROC curve analysis., Results: 196 patients were included (107 with SFU grade 3, 89 with SFU grade 4) hydronephrosis. Median patient age was 29[IQR 16,47.2] days. 10% had hypofunction, and 20% had T1/2 > 40 min 90% with hypofunction and 87% with high-risk drainage had SFU4 hydronephrosis. Model 1 exhibited the best performance, but on multivariate analysis, only APRPD and MPTR were independently associated with both outcomes. No other measure of parenchymal thickness reached statistical significance. The odds of hypofunction and high-risk drainage increase 10% per 1 mm increase in APRPD(aOR 1.1 [CI 1.03-1.2], p = 0.005; aOR 1.1 [CI 1.03-1.2], p = 0.003). For every 0.1unit increase in MPTR the odds of hypofunction decrease by 40%(aOR 0.6 [CI 0.4-0.9], p = 0.019); and the odds of high-risk drainage decrease by 30%(aOR 0.7 [CI 0.5-0.9], p = 0.011). Optimal statistical cut-points of APRPD >16 mm and/or MPTR <0.36 identified patients at risk for obstructive parameters on DR., Discussion and Conclusion: Of the sonographic hydronephrosis measurement variables analyzed, only APRPD and MPTR were independently associated with objective definitions of obstruction based on renal function and drainage categories. Patients who maintain APRPD <16 mm and/or MPTR >0.36 can potentially be monitored with renal sonograms as there is >90% chance that they will not have DRF<40% or T1/2 > 40 min., Competing Interests: Conflict of interest Neither I, nor any of the authors, have any conflicts of interest to disclose., (Copyright © 2024 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: To identify factors associated with overtreatment of presumed urinary tract infection (UTI) among children with spina bifida using such criteria., Study Design: A retrospective review of children with spina bifida (age <21 years) evaluated in the Emergency Department (ED) at a single institution was performed. Patients with a urinalysis (UA) performed who were reliant on assisted bladder emptying were included. The primary outcome was overtreatment, defined as receiving antibiotics for presumed UTI but ultimately not meeting spina bifida UTI criteria (≥2 urologic symptoms plus pyuria and urine culture growing >100k CFU/mL). The primary exposure was whether the components of the criteria available at the time of the ED visit (≥2 urologic symptoms plus pyuria) were met when antibiotics were initiated., Results: Among 236 ED encounters, overtreatment occurred in 80% of cases in which antibiotics were initiated (47% of the entire cohort). Pyuria with <2 urologic symptoms was the most important factor associated with overtreatment (OR 9.6). Non-Hispanic White race was associated with decreased odds of overtreatment (OR 0.3)., Conclusions: Overtreatment of presumed UTI among patients with spina bifida was common. Pyuria, which is not specific to UTI in this population, was the main driver of overtreatment. Symptoms are a cornerstone of UTI diagnosis among children with spina bifida, should be collected in a standardized manner, and considered in a decision to treat., Competing Interests: Declaration of Competing Interest No funding was secured for this study. The authors declare no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Children with Spina Bifida (SB) have considerable healthcare utilization, including Emergency Department use (EDU). We aimed to elicit reasons for EDU using qualitative analysis of interviews with both patient-caregiver dyads and stakeholders., Methods: A cohort of children with SB followed at our institution between 2016 and 2020 was identified and patient and clinical characteristics abstracted. Purposeful sampling by age and degree of past EDU was performed. Semi-structured interviews of dyads were performed using iteratively revised interview guides. Spanish-language interviews were conducted by a native Spanish speaker and transcripts professionally translated. Supplemental interviews with stakeholders, namely knowledgeable healthcare professionals, were also conducted. A qualitative framework approach was used for analysis, including open followed by closed independent coding with calculation of inter-rater reliability. A final interpretation of coding reports assessing convergence, divergence, and variation in themes across participant characteristics., Results: 116 families (4 Spanish-speaking) and 7 stakeholders were interviewed. Sampling yielded a heterogenous cohort for EDU (56% with 0-10, 44% with >10 visits) and age (25% 0-4, 44% 5-11, 31% > 11 years). IRR was optimal (κ = 0.9). Themes in perceived reasons for EDU were 1) desire for "one-stop-shop" care, 2) an emergent medical problem, 3) providers' instructions, 4) negative past healthcare experience, 5) intrinsic caregiver moderators, and 6) temporospatial influences. Themes 1, 2, and 5 predominated in dyads, whereas themes 6, 3, and 5 were most common in stakeholders. Stakeholders focused largely on negative institutional and patient characteristics. Among dyads only, theme #1 was disproportionately emphasized by Spanish-speaking patients., Discussion: Families desired access to coordinated expert care, testing and imaging. The ED offers this for children with SB, regardless of clinical acuity. This may be especially valued by families with inherent challenges to navigating the healthcare system. Negative experiences in community clinical settings, healthcare provider recommendations and intrinsic parental factors were themes that seemed to contribute to seeking this "one-stop-shop" type of care. Care coordination may reduce ED reliance, but themes for the interviews suggest a systems-based efforts should weave in the community care setting., Conclusions: For both stakeholders and caregivers, the ED represented a valued form of immediate access to multispecialty, expert care and testing in the context of perceived lack of timely, coordinated outpatient care. This may be moderated by intrinsic caregiver factors and negative past experiences. Although stakeholders discussed ideas that fit into patient-caregiver themes, the also uniquely focused on systems-based and patient-caregiver limitations., Competing Interests: Conflict of interest None., (Copyright © 2024. Published by Elsevier Ltd.)

Purpose: Urodynamic testing (UDS) is an important tool in the management of pediatric lower urinary tract conditions. There have been notable efforts to standardize pediatric UDS nomenclature and technique, but no formal guidelines exist on essential elements to include in a clinical report. We sought to identify ideal structure and elements of a pediatric UDS assessment based on expert consensus., Materials and Methods: Pediatric urologists regularly performing UDS were queried using a Delphi process. Participants were invited representing varied geographic, experience, and societal involvement. Participants underwent 3 rounds of questionnaires between November 2022 and August 2023 focusing on report organization, elements, definitions, and automated electronic health record clinical decision support. Professional billing requirements were also considered. Consensus was defined as 80% agreeing either in favor of or against a topic. Elements without consensus were discussed in subsequent rounds., Results: A diverse sample of 30 providers, representing 27 institutions across 21 US states; Washington, District of Columbia; and Canada completed the study. Participants reported interpreting an average number of 5 UDS reports per week (range 1-22). The finalized consensus report identifies 93 elements that should be included in a pediatric UDS report based on applicable study conditions and findings., Conclusions: This consensus report details the key elements and structure agreed upon by an expert panel of pediatric urologists. Further standardization of documentation should aid collaboration and research for patients undergoing UDS. Based on this information, development of a standardized UDS report template using electronic health record implementation principles is underway, which will be openly available for pediatric urologists.

Objective: To present a unique series of children with previously repaired anorectal malformations (ARM) with subsequent urethral pathology repaired via a posterior sagittal exposure and highlight the associated technical advantages., Methods: Using a retrospective review of all procedures performed in our pediatric colorectal and pelvic reconstruction program from January 2020 through December 2022, we compiled a case series of patients with a history of ARM and prior posterior sagittal anorectoplasty (PSARP) who had urethral pathology and concurrent indication for redo-PSARP. Clinical features, operative details, and postoperative outcomes were collected., Results: Six male patients presented at a median age of 4.3 years, all born with an ARM of recto-urinary fistula type, of which 3 were recto-prostatic, 1 recto-bladder-neck, and 2 unknown type. In addition to redo-PSARP, 2 underwent remnant of the original fistula excision and 4 had urethral stricture repair. One required post-operative Heineke-Mikulicz anoplasty. Patients underwent cystoscopy 4-6 weeks post-reconstruction, and none showed urethral stricture requiring treatment. Post-procedurally, 5 patients were able to void urethrally and 1 required additional bladder augmentation/Mitrofanoff., Conclusion: Redo-PSARP completely mobilizes the rectum, thereby providing excellent exposure to the posterior urethra for repair. This approach also allows the option of a rectal flap for augmented urethroplasty as well as harvest of an ischiorectal fat pad for interposition., Competing Interests: Declaration of Competing Interest All authors have no disclosures or conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Uroflowmetry is a non-invasive study used in the diagnosis and monitoring of treatment response for lower urinary tract disorders. For optimal clinical utility, uroflow studies rely on careful clinical interpretation by a trained provider, but currently there is a lack of accepted standardized normal values for the measured uroflow parameters in children. The International Children's Continence Society proposed standardizing the terminology for uroflow curve shapes. However, the patterning of curves is largely at the physician's subjective discretion., Objectives: The aims of this study were to understand inter-rater reliability in interpreting uroflow curves and to define characteristics of uroflow curves that could be used to provide definitive criteria for uroflowmetry parameters., Methods: All members of the SPU Voiding dysfunction Task Force were invited to contribute deidentified uroflows to a centralized HIPAA complaint receiving database. All studies were then distributed to all raters for review. Each observer's findings were recorded according to ICCS criteria (ICCS), additional readings were done using a previously reported system which defined curves as smooth or fractionated (SF) and whether the shape resembled a bell, tower, or plateau (BTP). Flow indexes (Qact/Qest) (FI) for Qmax and Qavg were generated using formulas previously reported for children 4-12 and for patients≥12 years., Results: A total of 119 uroflow studies were read by 7 raters and curves were contributed from 5 sites. Kappa scores for the 5 readers from different institutions were 0.34 and 0.28 for the ICCS and BTP methods, respectively (both considered fair agreement). Kappa for smooth and fractionated curves was 0.70 (for each; considered substantial agreement), which were the two highest agreement scores obtained throughout the study. Discriminant analysis (DA) revealed that the FI Qmax was the dominant vector, and that the ICCS uroflow parameters have a total of 42.8% prediction rate in the training sample. Using DA of a smooth/fractionated system, the total prediction rates were 72% and 65.5% for smooth and fractionated, respectively., Discussion: Given the poor inter-rater agreement for analyzing uroflow curve pattern based on ICCS criteria in this study and others, one may find it reasonable to consider alternative approaches to describing and characterizing uroflow curves. Our study is limited by lack of EMG and post-void residual data., Conclusions: For a more objective uroflow interpretation and comparison of studies among different centers, we recommend using our proposed system (based on FI, and smooth vs. fractionated curve pattern), which is more reliable., Competing Interests: Conflicts of interest JVB is a co-inventor on United States Patent Application No. 62/890,169 and is a scientific advisor for UroGenie, LLC, neither of which is under investigation in the current study. IF holds multiple patents: U.S. Patent Number: 10, 905, 368 B2, U.S. Patent Application No.: 15/485,046, U.S. Patent Number 10, 685, 249B2, U.S. Patent Number 16472,002; patent pending on US Patent Appl. No. 17177,774. IF is also chief scientific officer of GoGoband® and equity owner in the company, he is also a member of advisory committee of DriHealth and is a consultant for Astellas. None of the above are involved in the study., (Copyright © 2023 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Introduction/background: Although the combination of bladder dysfunction and upper tract anomalies puts patient with cloaca at risk for renal disease, the rarity of this condition makes it difficult to study empirically. As a high-volume center, we uniquely capture bladder function outcomes following our growing number of cloacal repairs., Objective: 1) Describe the rates of incomplete bladder emptying following primary cloacal repair (at 2-3 months after repair and last follow up), and 2) identify clinical factors associated with assisted bladder emptying., Study Design: We performed a prospective cohort study of patients undergoing primary cloaca repair by our Children's National Colorectal Center team between 2020 and 2021. The primary outcome was assisted bladder emptying at 2-3 months postoperatively and last visit. Covariables included preoperative characteristics (cloacagram measurements), ARM complexity (moderate = common channel [CC] <3-cm, severe = CC ≥ 3-cm), vesicoureteral reflux (VUR) status, sacral ratio (good ≥0.7, intermediate 0.7-0.4, poor ≤0.4), spinal cord status, means of preoperative bladder emptying, and operative details (age at repair, repair type, & concomitant laparotomy)., Results: Eighteen participants were eligible. A majority had moderate cloaca (78%), VUR (67%), spinal cord abnormalities (89%), and good sacral ratios (56%). Preoperatively, 10 patients were diapered for urine and 8 had assisted bladder emptying. Surgical repairs were performed at a median age of 8 months (range 4-46). Nine (50%) patients underwent urogenital separation (UGS), eight (44%) total urogenital mobilization, and 1 (6%) perineal sparing posterior sagittal anorectoplasty with introitoplasty. Exploratory laparotomy was performed in 7 (39%) patients. At 2-3 months, 7 patients were voiding and 11 required assisted bladder emptying. Median length of long-term follow up was 12 months (range 5-25), and 8 patients were voiding and 10 required assisted bladder emptying. Postoperative need for assisted bladder emptying was significantly associated with assisted bladder emptying preoperatively, a shorter urethra and increasing common channel length, UGS and exploratory laparotomy. Spinal cord imaging findings were not associated., Discussion: Bladder emptying following cloaca repair is likely a result of congenital function and surgical effects. Indeed, increasingly cloaca complexity requiring UGS and laparotomy was associated with both pre- and post-operative assisted bladder emptying. The lack of association with spinal cord imaging may reflect a divergence between anatomy and function., Conclusion: Approximately half of patients required assisted bladder emptying in this study. Associated factors included urethral and common channel length, the need for assisted bladder emptying preoperatively, the type of surgical approach and additional laparotomy. Being diapered with seemingly normal voiding prior to surgery did not guarantee normal bladder function postoperatively., (Copyright © 2023 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

A ureterocele is a congenital cystic dilatation of the intravesical ureter that may affect either a single system kidney or the upper pole of a duplex system. The position of ureteral orifice correlates with function of associated renal moiety. Ureteroceles associated with good renal function and prompt drainage or ureteroceles associated with no renal function can be managed nonoperatively. Endoscopic puncture of ureteroceles addresses most cases; iatrogenic reflux may rarely require secondary surgery. Robot-assisted laparoscopic upper pole nephroureterectomy and ureteroureterostomy procedures are rarely associated with complications., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background/objective: While there is significant data on the natural history and outcomes for prenatal hydronephrosis in simplex kidneys, duplex kidneys tend to be less studied. Management can be quite variable based on provider preference. We aimed to describe practice patterns from several tertiary academic institutions, identify clinical predictors for surgical intervention and urinary tract infection (UTI) for upper pole pathology, and demonstrate the natural history of lower pole vesicoureteral reflux (VUR)., Methods: We conducted a retrospective review of patients from 4 Mid-Atlantic institutions between 2015 and 2020. Inclusion criteria included patients with a duplex kidney with upper pole pathology and/or lower pole VUR. The primary outcome was predictive factors for surgical intervention and UTI. The secondary outcome was to assess the natural history of lower pole VUR including resolution rates by grade. Linear regression identified clinical predictors for UTI events. Multivariate logistic regression identified predictors of surgical intervention, UTI, and lower pole VUR resolution. Descriptive statistics and regression modeling analyses were performed using SAS., Results: Two hundred forty-two patients were included with a total of 271 duplex renal units. Hydronephrosis grade (both SFU and UTD grading) and number of prior UTI events were statistically significant predictors for surgical intervention (p = 0.03/0.001 and p = 0.002 respectively). Ectopic ureter (p = 0.004), ureterocele (p = 0.02), and obstruction (p = 0.04) were the only pathologies predictive for surgery. Male gender and circumcision were significantly associated with decreased UTI risk (p = 0.03 and p = 0.01). On linear regression modeling, antibiotic prophylaxis after the first year of life was associated with decreased risk of further UTI events (p = 0.03); however, antibiotic prophylaxis within the first year of life did not decrease UTI risk (p = 0.14). For VUR outcomes, 65.0% of grades 1-3 VUR and 52.2% of grades 4-5 had resolution/improvement at mean time of 2.1 years. There were no predictive factors for resolution/improvement of VUR., Conclusions: Hydronephrosis grade and UTI events were significant predictors for surgical intervention for upper pole pathology. Pathologies that were predictive for surgery included ectopic ureter, ureterocele and obstruction. Male gender, circumcision and antibiotic prophylaxis after the first year of life were associated with a decreased UTI risk. Roughly 58% of lower pole VUR spontaneously improved/resolved. Identification of these risk factors aids in standardization of care practices to reduce long-term UTI risk and inform counseling with families about possible need for surgical intervention and expectations for long term outcomes., (Copyright © 2022 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Cloaca is a rare, complex malformation encompassing the genitourinary and anorectal tract of the female in which these tracts fail to separate in utero, resulting in a single perineal orifice. Prenatal sonography detects a few cases with findings such as renal and urinary tract malformations, intraluminal calcifications, dilated bowel, ambiguous genitalia, a cystic pelvic mass, or identification of other associated anomalies prompting further imaging. Multi-disciplinary collaboration between neonatology, pediatric surgery, urology, and gynecology is paramount to achieving safe outcomes. Perinatal evaluation and management may include treatment of cardiopulmonary and renal anomalies, administration of prophylactic antibiotics, ensuring egress of urine and evaluation of hydronephrosis, drainage of a hydrocolpos, and creation of a colostomy for stool diversion. Additional imaging of the spinal cord and sacrum are obtained to plan possible neurosurgical intervention as well as prognostication of future bladder and bowel control. Endoscopic evaluation and cloacagram, followed by primary reconstruction, are performed by a multidisciplinary team outside of the neonatal period. Long-term multidisciplinary follow-up is essential given the increased rates of renal disease, neuropathic bladder, tethered cord syndrome, and stooling issues. Patients and families will also require support through the functional and psychosocial changes in puberty, adolescence, and young adulthood.

Introduction: Healthcare disparities have been shown to impact outcomes of various acute pediatric conditions. We sought to examine the impact of race, ethnicity and insurance status on the presentation, management and outcome of testicular torsion., Materials and Methods: A retrospective review of a prospectively maintained testicular torsion database was performed. Patients ≤18 years of age evaluated in our pediatric institution's emergency room between April 2016-April 2020 with US diagnosed and OR confirmed testicular torsion were included. Basic demographics, timing of presentation, referral rate, time to OR and orchiectomy rate were extracted and compared. P < 0.05 was considered statistically significant., Results: A total of 206 patients were included. 114 (56.2%) were Black or African American (Black/AA), 43 were (21.2%) Hispanic/Latino, 22 (10.8%) were Caucasian, and 24 (11.8%) were designated as Other races. Ninety-eight (48.3%) patients had Medicaid, 90 (44.3%) had private insurance, and 15 (7.4%) patients were uninsured. Sixty-eight (33.0%) presented in a delayed fashion (>24 h). Compared to the Caucasian patients, Black/AA patients were 2.1 years (95% CI: 0.5, 3.8; P = 0.010) older at the time of presentation. When compared to those with Medicaid insurance, uninsured patients had 6.26 times (95% CI: 1.58, 41.88; P = 0.021) higher odds to be referred from an outside hospital for management. In those patients presenting acutely (<24 h, N = 138), there were no significant differences in the odds of orchiectomy for Black/AA or Hispanic/Latino patients when compared to Caucasian patients, however, the odds of orchiectomy in Other races (non-Caucasian, non-Black/AA, non-Hispanic/Latino) was significantly higher (OR: 10.38; 95% CI: 1.13, 246.96; P = 0.049). While the mean time in minutes from ED to OR was longer in those with Medicaid insurance (141 vs 125.4 private vs 115 uninsured, p = 0.042), this did not impact orchiectomy rate (39.8% vs 40.9% vs 46.7%, p = 0.88)., Conclusions: We found no differences in the orchiectomy rates by race with the exception of a higher rate in the diverse and heterogeneous Other race (non-Caucasian, non-Black/AA, non-Hispanic/Latino) group. Those uninsured had a higher referral rate highlighting the potential existence of disparities for those uninsured and the need for further investigation., Competing Interests: Declarations of interest None., (Copyright © 2022 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

INTRODUCTION To examine the impact of COVID-19 pandemic on the presentation, management and outcome of testicular torsion at our institution., Materials and Methods: A retrospective review of a prospectively maintained testicular torsion database was performed. Patients ≤ 18 years of age evaluated in our emergency room between 3/11/2020 to 10/1/2020 (during-COVID-19) and the same period in 2018 and 2019 (pre-COVID-19) with US diagnosed and OR confirmed testicular torsion were included. Basic demographics, timing of presentation, referral rate, time to OR and orchiectomy rate were extracted and compared. P < 0.05 was considered statistically significant., Results: A total of 82 torsions were included in the study; 55 pre-COVID-19 and 27 during-COVID-19. The incidence of testicular torsion remained the same; 3.93 cases/month pre-COVID-19 versus 3.86 cases/month during-COVID-19 (p = 0.791). However, there were significantly fewer delayed (> 24 hours) presentations (11.1% versus 45.5% , p = 0.003), shorter time from onset of symptoms to presentation (median 15.5 hours versus 8 hours, p = 0.001), and a lower but not statistically significant overall orchiectomy rate (33.3% versus 50.9% p = 0.1608) during-COVID-19. Among those presenting acutely with torsion (< 24 hours from onset), no statistical differences were found in the median time from US diagnosis to OR, from ED to OR, referral rate, or orchiectomy rate between the two groups. Lastly, SARS-CoV2 testing did not delay median time from ED to OR., Conclusions: There was a notably less delayed presentation of testicular torsion and shorter ischemia time on presentation during-COVID, however, no significant change of time to OR or orchiectomy rate in those with acute testicular torsion were observed.

Introduction and Objective: Prior studies have shown a broad half time (T1/2) interval on MAG3 diuresis renography (DR) that is indeterminate for obstruction. We aimed to refine and sub-divide the indeterminate range and associate it with clinically meaningful outcomes: pyeloplasty and pyeloplasty-free survival., Methods: We identified patients <1.5 years-old at presentation with unilateral, isolated moderate to severe hydronephrosis who underwent DR from 2000 to 2016. A logistic regression model was created using T1/2 to predict surgery. An indeterminate range was defined based on patients with <90% probability of pyeloplasty or resolution. This group was sub-divided into three T1/2 intervals: 5-20, 21-40, and 41-60 min. Endpoints were pyeloplasty and pyeloplasty free survival. Indications for surgery were loss of differential renal function (DRF), worsening T1/2, family preference, and/or pain., Results: Among 2025 patients with DR, 704 met criteria (169 were lost to follow up). Of the remaining 535, 218 had pyeloplasties and 317 did not. The Pyeloplasty group had significantly worse DRF, T1/2 at initial DR, and exited the study earlier, at a median age 1.1years vs 2.3 years (p < 0.001). For all patients with antenatally detected unilateral UPJ obstruction, the odds of undergoing pyeloplasty at any time increased by 1.8 times (p < 0.001 [95% CI: 1.04, 1.08]) per 10 unit increase in T1/2 until T1/2 = 60. However, in patients with intermediate drainage, five year surgery-free survival probability for patients with T1/2 5-20, 21-40, and 41-60 min were 79.7%, 46.7% and 33.3% respectively (χ2 = 41.2, P = <0.001)., Discussion: Previous efforts to define indeterminate drainage resulted in ranges for T1/2 that were too broad to be clinically useful. Within our endpoint-defined indeterminate range, our data show that there are significant step offs in 5-year surgery-free survival for patients with T1/2 < 20 min, 21-40 min, and 41-60 min. Although there is a steady decrease in surgery-free survival among patients with a T1/2 of 21-40 min over the first 5 years of life, half can be managed nonoperatively. These patients likely represent the true intermediate risk group and closer follow up is justified., Conclusions: Initial T1/2 on DR is predictive of future surgery. When drainage is "indeterminate" for obstruction, sub-stratification allows for more accurate prognostication., Competing Interests: Conflicts of interest Neither I, nor any of the other authors, have any financial disclosures or conflicts of interest., (Copyright © 2021 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: To evaluate the efficacy of adjuvant systemic corticosteroids in reducing kidney scarring. A previous study suggested that use of adjuvant systemic corticosteroids reduces kidney scarring in children radiologically confirmed to have extensive pyelonephritis. Efficacy of corticosteroids for children with febrile urinary tract infection (UTI) has not been studied., Methods: Children aged 2 months to 6 years with their first febrile UTI were randomized to corticosteroids or placebo for 3 days (both arms received antimicrobial therapy); kidney scarring was assessed using 99m Tc-dimercaptosuccinic acid kidney scan 5-24 months after the initial UTI., Results: We randomized 546 children of which 385 had a UTI and 254 had outcome kidney scans (instead of the 320 planned). Rates of kidney scarring were 9.8% (12/123) and 16.8% (22/131) in the corticosteroid and placebo groups, respectively (p = 0.16), corresponding to an absolute risk reduction of 5.9% (95% confidence interval: - 2.2, 14.1)., Conclusion: While children randomized to adjuvant corticosteroids tended to develop fewer kidney scars than children who were randomized to receive placebo, a statistically significant difference was not achieved. However, the study was limited by not reaching its intended sample size., Clinical Trial Registration: Clinicaltrials.gov , NCT01391793, Registered 7/12/2011 Graphical abstract.

Purpose: Compared to the microbiome of other body sites, the urinary microbiome remains poorly understood. Although noninvasive voided urine specimens are convenient, contamination by urethral microbiota may confound understanding of the bladder microbiome. Herein we compared the voiding- versus catheterization-associated urine microbiome of healthy men and women., Methods: An asymptomatic, healthy cohort of 6 women and 14 men underwent midstream urine collection, followed by sterile catheterization of the bladder after bladder refilling. Urine samples underwent urine dipstick testing and conventional microscopy and urine cultures. Samples also underwent Illumina MiSeq-based 16S ribosomal RNA gene amplification and sequencing., Results: All organisms identified by urine culture were also identified by 16S amplification; however, next-generation sequencing (NGS) also detected bacteria not identified by cultivation. Lactobacillus and Streptococcus were the most abundant species. Abundances of the 9 predominant bacterial genera differed between the urethra and bladder. Voided and catheterized microbiomes share all dominant (>1%) genera and Operational Taxonomic Units but in similar or different proportions. Hence, urethra and bladder microbiomes do not differ in taxonomic composition, but rather in taxonomic structure. Women had higher abundance of Lactobacillus and Prevotella than men., Conclusion: Our findings lend credence to the hypothesis that Lactobacilli are important members of the healthy urine microbiome. Our data also suggest that the microbiomes of the urethra and bladder differ from one another. In conclusion, urine collection method results in different 16S-based NGS data, likely due to the sensitivity of NGS methods enabling detection of urethral bacteria present in voided but not catheterized urine specimens.

Purpose: Complication rates of 5% to 10% and 12% to 23% have been observed following distal and proximal hypospadias repair, respectively. However, these rates may be overreported. We hypothesized that data from the Pediatric Health Information System would corroborate the complication rates reported in the literature and refute the rates established by U.S. News & World Report as quality metrics., Materials and Methods: The Pediatric Health Information System database was interrogated for hypospadias and revision CPT® codes. To evaluate the appropriateness of the U.S. News & World Report code list to identify revisions, 3 CPT groups were defined. Group A included codes sought by U.S. News & World Report, group B included group A plus codes for acquired urethrocutaneous fistula in males and group C included group B plus any revision codes associated with the index procedures. To evaluate the appropriateness of U.S. News & World Report followup interval, we assessed revision rates with ever increasing followup intervals out to 7 years. Yearly revision rates were summarized by median and quantile to correlate whether median revision rates changed significantly depending on whether increased followup or enhanced code lists were used., Results: Average complication rates for group A were 3.32% (range 0.48% to 7.36%) and 12.29% (3.48% to 36.36%) for distal and proximal repairs, respectively. Revision rates increased significantly from group A (median 3.32%) by inclusion of a more expansive list of CPT codes associated with revision procedures (group B, 4.26%, p <0.001 and group C, 6.37%, p <0.001) in distal hypospadias. Among proximal hypospadias cases this difference was not significant when comparing group A (12.29%) to group B (12.53%, p=0.813), but was significant when comparing group A to group C (22.14%, p <0.001). Median revision rates for distal and proximal hypospadias increased with longer followup for all 3 groups, although the upward trend was not statistically significant., Conclusions: Depending on how one defines hypospadias revision, no hospital within the Pediatric Health Information System data set meets the U.S. News & World Report definition of perfection, a finding that is supported by recent reports from some of the largest, most prolific and most highly regarded pediatric urology programs. We posit that the U.S. News & World Report quality metrics do not accurately reflect the nature of hypospadias surgery complication rates.

Objective: To determine pediatric urologists' antibiotic prophylaxis prescribing practices for children with vesicoureteral reflux (VUR) and other congenital anomalies of the kidney and urinary tract (CAKUT)., Methods: Web-based survey of pediatric urologists about their practice of antibiotic prophylaxis in children with CAKUT., Results: We had a response rate of 17.8% (n = 73). The majority of respondents always or often prescribe prophylactic antibiotics for grade IV or V VUR, while greater variability was seen for lower grades of VUR. 47.9% of respondents report that they often or always prescribe antibiotics for patients with grade 4 hydronephrosis, and most respondents report that they never or rarely prescribe antibiotics for grade 1 or 2 hydronephrosis. The majority of respondents never or rarely prescribe antibiotics for horseshoe or solitary kidney (88% and 86%, respectively), but frequently prescribed antibiotic for ureterocele. For ectopic ureter, almost half of respondents prescribe prophylactic antibiotics always or often, whereas only 18% prescribe antibiotics always or often for duplication anomalies. Only 11% reported prescribing antibiotics for prophylaxis always or often for children with myelomeningocele., Conclusion: We report notable variability in antibiotic prescribing patterns for children with CAKUT. Given the lack of guidelines around the use of prophylaxis in the majority of these conditions, standardization of care may be warranted to decrease this variability., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Antimicrobial prophylaxis for children with vesicoureteral reflux (VUR) reduces recurrences of urinary tract infection (UTI) but requires daily antimicrobials for extended periods. We used a cost-utility model to evaluate whether the benefits of antimicrobial prophylaxis outweigh its risks and, if so, to investigate whether the benefits and risks vary according to grade of VUR. Methods: We compared the cost per quality-adjusted life-year (QALY) gained in four treatment strategies in children aged <6 years diagnosed with VUR after a first UTI, considering these treatment strategies: (1) prophylaxis for all children with VUR, (2) prophylaxis for children with Grade III or Grade IV VUR, (3) prophylaxis for children with Grade IV VUR, and (4) no prophylaxis. Costs and effectiveness were estimated over the patient's lifetime. We used $100,000/QALY gained as the threshold for considering a treatment strategy cost effective. Results: Based on current data and plausible ranges to account for data uncertainty, prophylaxis of children with Grades IV VUR costs $37,903 per QALY gained. Treating children with Grade III and IV VUR costs an additional $302,024 per QALY gained. Treating children with all grades of VUR costs an additional $339,740 per QALY gained. Conclusions: Treating children with Grades I, II, and III VUR with long-term antimicrobial prophylaxis costs substantially more than interventions typically considered economically reasonable. Prophylaxis in children with Grade IV VUR is cost effective., (Copyright © 2020 Shaikh, Rajakumar, Peterson, Gorski, Ivanova, Gravens Muller, Miyashita, Smith, Mattoo, Pohl, Mathews, Greenfield, Docimo and Hoberman.)

Background: Timely diagnosis and management of testicular torsion is of paramount importance. Furthermore, time to surgical intervention is a benchmark for the quality of care provided by pediatric urologists included in US News and World Report (USNWR) methodology., Objective: We sought to optimize management of acute testicular torsion at a single institution by decreasing time from presentation to definitive management through the creation and implementation of a clinical care pathway (accelerated care of torsion or ACT) for acute testicular torsion in a 2-year period., Study Design: Multidisciplinary process mapping involving the emergency department (ED), radiology, anesthesiology, peri-operative services, and operating room (OR) teams resulted in development of the ACT pathway with the goal of achieving surgical intervention within 4 h of arrival at our institution. The accelerated care of torsion pathway was implemented in April 2016. Thirty-eight consecutive acute torsion cases were then prospectively evaluated from April 2016 to April 2018. For process measures, we recorded triage to OR times and mode of presentation. For outcome measures, we examined orchiectomy rates. We retrospectively reviewed 97 cases of acute torsion from 2004 to 2016 as a control., Results: Time from ED triage to OR start decreased from a median 196 min (interquartile range [IQR] 137-249 min) to 127 min (IQR 100-148 min; P < 0.0001) for all cases of acute torsion. In the control group, 72% of cases met the USNWR criteria for acute treatment of torsion. After ACT implementation, 100% of cases reached the OR within the 240 min time frame. Orchiectomy rates were performed in 24% of control cases vs 30% after ACT implementation (P = NS). Survival curve analysis demonstrated no significant difference in probability of testis salvage before or after implementation of the ACT pathway., Discussion: In agreement with similar studies, despite a significant reduction in triage to OR times, the orchiectomy rate approached 30%. This outcome did not significantly improve after implementation of the ACT pathway. Overall ischemia time was a more important determinant of testis salvage. Study limitations include limited patient follow-up to assess testis atrophy., Conclusions: The multidisciplinary creation and implementation of a clinical pathway for the care of acute testis torsion has significantly decreased the time from ED to OR in our institution. However, overall orchiectomy rate was not significantly affected., (Copyright © 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Stomal prolapse is a known late complication of urinary diversions commonly used in urology. While rare, it can lead to ischemia, necrosis, and obstruction of the stoma, requiring urgent reduction before formal revision can be undertaken. Several measures can be attempted to reduce the prolapse including manual pressure and topical osmotic agents. One method that has not been reported in the urologic literature is the use of hyaluronidase. Herein, we report the first case in the literature of hyaluronidase usage to assist in reduction of an ischemic and obstructed prolapsed incontinent ileovesicostomy after manual compression failed., (Copyright © 2018 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Introduction: People with neuropathic bladder (NB) secondary to spinal cord injury (SCI) are at risk for multiple genitourinary complications, the most frequent of which is urinary tract infection (UTI). Despite the high frequency with which UTI occurs, our understanding of the role of urinary microbes in health and disease is limited. In this paper, we present the first prospective case study integrating symptom reporting, urinalysis, urine cultivation, and 16S ribosomal ribonucleic acid (rRNA) sequencing of the urine microbiome., Case Presentation: A 55-year-old male with NB secondary to SCI contributed 12 urine samples over an 8-month period during asymptomatic, symptomatic, and postantibiotic periods. All bacteria identified on culture were present on 16S rRNA sequencing, however, 16S rRNA sequencing revealed the presence of bacteria not isolated on culture. In particular, Burkholderia fungorum was present in three samples during both asymptomatic and symptomatic periods. White blood cells of ≥5-10/high power field and leukocyte esterase ≥2 on urinalysis was associated with the presence of symptoms., Discussion: In this patient, there was a predominance of pathogenic bacteria and a lack of putative probiotic bacteria during both symptomatic and asymptomatic states. Urinalysis-defined inflammatory markers were present to a greater extent during symptomatic periods compared to the asymptomatic state, which may underscore a role for urinalysis or other inflammatory markers in differentiating asymptomatic bacteriuria from UTI in patients with NB. The finding of potentially pathogenic bacteria identified by sequencing but not cultivation, suggests a need for greater understanding of the relationships amongst bacterial species in the bacteriuric neuropathic bladder., Competing Interests: Compliance with ethical standardsThe authors declare that they have no conflict of interest.

Purpose: We sought to define features that describe the dynamic information in diuresis renograms for the early detection of clinically significant hydronephrosis caused by ureteropelvic junction obstruction., Materials and Methods: We studied the diuresis renogram of 55 patients with a mean ± SD age of 75 ± 66 days who had congenital hydronephrosis at initial presentation. Five patients had bilaterally affected kidneys for a total of 60 diuresis renograms. Surgery was performed on 35 kidneys. We extracted 45 features based on curve shape and wavelet analysis from the drainage curves recorded after furosemide administration. The optimal features were selected as the combination that maximized the ROC AUC obtained from a linear support vector machine classifier trained to classify patients as with or without obstruction. Using these optimal features we performed leave 1 out cross validation to estimate the accuracy, sensitivity and specificity of our framework. Results were compared to those obtained using post-diuresis drainage half-time and the percent of clearance after 30 minutes., Results: Our framework had 93% accuracy, including 91% sensitivity and 96% specificity, to predict surgical cases. This was a significant improvement over the same accuracy of 82%, including 71% sensitivity and 96% specificity obtained from half-time and 30-minute clearance using the optimal thresholds of 24.57 minutes and 55.77%, respectively., Conclusions: Our machine learning framework significantly improved the diagnostic accuracy of clinically significant hydronephrosis compared to half-time and 30-minute clearance. This aids in the clinical decision making process by offering a tool for earlier detection of severe cases and it has the potential to reduce the number of diuresis renograms required for diagnosis., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

We identified factors associated with delay in presentation and misdiagnosis of testicular torsion. Compared with acute cases, delayed presentations were more likely to report isolated abdominal pain, developmental disorders, and history of recent genital trauma. Failure to perform a genitourinary examination or scrotal imaging was associated with misdiagnosis., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Hypospadias is commonly assessed and repaired by pediatric urologists. Mild, distal hypospadias is generally more a cosmetic problem than a functional one and is more frequently encountered than severe, proximal hypospadias. Outcomes following repair, especially of mild phenotypes, are important to understand, but range widely in timing and measurability. Surgical complications, postoperative satisfaction of parents, patients, surgeons and even lay observers, urinary function, sexual function, and quality of life all may be considered as relevant outcomes of hypospadias repair. Existing studies examining these outcomes are diverse in their conclusions, but are important to understand when counseling parents and patients prior to any surgical intervention., (Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: In infants with SFU (Society for Fetal Urology) grade 3-4 congenital hydronephrosis, 99m Tc-mercaptoacetyltriglycine diuretic renography assesses differential function and drainage half-time. We routinely also include the percent of radiotracer drained after 30 minutes of diuresis as well as after 15 minutes with the patient in the upright position. We investigated whether any 1 or more of these parameters on initial diuretic renography predicts persistent or worsening drainage parameters., Materials and Methods: Infants 6 months or younger with grade 3-4 congenital hydronephrosis who presented between January 2009 and December 2014 were identified from billing data and included in analysis if they underwent at least 1 baseline diuretic renography. Those with structural anomalies were excluded from study. Baseline and followup differential function, diuresis half-time, clearance at 30 minutes and clearance with the patient upright were abstracted and comparisons were made between those with initially indeterminate diuresis half-time who underwent pyeloplasty vs those showing spontaneous improvement., Results: A total of 74 patients (82 renal units) with presumed ureteropelvic junction obstruction met inclusion/exclusion criteria. All 10 renal units with initial diuresis half-time less than 5 minutes resolved spontaneously and all 25 renal units with initial diuresis half-time greater than 75 minutes underwent pyeloplasty. Therefore, we defined the indeterminate group as the 47 renal units with initial half-time between 5 and 75 minutes. Of those 47 renal units with indeterminate initial diuresis half-time 23 (47%) underwent pyeloplasty and 25 (53%) resolved spontaneously. Indications for pyeloplasty included worsening in 17 cases, persistent obstruction in 4 and urinary tract infection in 1. Among renal units with indeterminate drainage clearance while upright and clearance at 30 minutes were the only variables that differed significantly between surgical cases and those that resolved spontaneously., Conclusions: Radiotracer clearance with the patient upright and clearance at 30 minutes are more predictive of surgical management than diuresis half-time or differential function for renal units with indeterminate drainage. They should be included in the standard assessment of ureteropelvic junction obstruction., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We examined testicular torsion presentation and referral trends at our institution before and after pediatric urology subspecialty certification., Materials and Methods: We reviewed patients with testicular torsion presenting directly to our pediatric hospital emergency department ("direct") or transferred urgently from an outside institution ("referred") who underwent detorsion and orchiopexy or orchiectomy between 2005 and 2015. Presentations were considered acute (less than 24 hours) or delayed (24 hours or greater) based on time from symptom onset. Primary outcomes were case volume and presentation trends through time. Secondary outcomes were effect of presenting location and transport variables on orchiectomy rate., Results: Incidence of testicular torsion increased from 15 cases in 2005 to 32 in 2015. Annual incidence of direct cases increased slightly during the study period from 12 to 17, whereas incidence of referred cases increased from 3 in 2005 to 15 in 2015. Proportion of referred acute cases markedly increased from precertification (4 of 63, 6.3%) to postcertification period (42 of 155, 27.1%; p <0.01). The majority of referred cases (59 of 83, 71.1%) presented during weekday nights or weekends compared to a minority of direct cases (59 of 135, 43.7%; p <0.01). Orchiectomy rates were similar between direct and referred cases across all study periods and were not significantly impacted by presentation location, transport distance or transport modality (all p >0.05)., Conclusions: Patients with testicular torsion have been increasingly referred to our institution, with the majority presenting on weekday nights and weekends. Our data do not support routinely transferring these patients to dedicated pediatric hospitals., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We used the PathoScope platform to perform species level analyses of publicly available, 16S rRNA pyrosequenced, asymptomatic urine data to determine relationships between microbiomes, and clinical and functional phenotypes., Materials and Methods: We reanalyzed previously reported, cross-sectionally acquired urine samples from 47 asymptomatic subjects, including 23 controls and 24 subjects with neuropathic bladder. Urine was originally collected by the usual method of bladder drainage and analyzed by urinalysis, culture and pyrosequencing. Urinalysis and culture values were stratified as leukocyte esterase (0, or 1 or greater), nitrite (positive or negative), pyuria (fewer than 5, or 5 or greater white blood cells per high power field), cloudy urine (positive or negative) and urine culture bacterial growth (less than 50,000, or 50,000 or greater cfu/ml). PathoScope was used for next generation sequencing alignment, bacterial classification and microbial diversity characterization., Results: Subjects with neuropathic bladder were significantly more likely to have positive leukocyte esterase and pyuria, cloudy urine and bacterial growth. Of 47 samples 23 showed bacterial growth on culture and in all samples bacteria were identified by pyrosequencing. Nonneuropathic bladder urine microbiomes included greater proportions of Lactobacillus crispatus in females and Staphylococcus haemolyticus in males. The Lactobacillus community differed significantly among females depending on bladder function. Irrespective of gender the subjects with neuropathic bladder had greater proportions of Enterococcus faecalis, Proteus mirabilis and Klebsiella pneumonia. In 4 subjects with neuropathic bladder Actinobaculum sp. was detected by sequencing and by PathoScope but not by cultivation and in all cases it was associated with pyuria., Conclusions: Using PathoScope plus 16S pyrosequencing we were able to identify unique, phenotype dependent, species level microbes. Novel findings included absent L. crispatus in the urine of females with neuropathic bladder and the presence of Actinobaculum only in subjects with neuropathic bladder., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Catheter associated urinary tract infections are an essential measure for health care quality improvement that affects reimbursement through hospital acquired condition reduction programs in adult patients. With the mounting importance of preventing such infections we evaluated risk factors for acquiring catheter associated urinary tract infections in pediatric patients., Materials and Methods: All catheter associated urinary tract infections were identified at 1 pediatric institution from September 2010 to August 2014 from a prospective database maintained by the infection control office. To identify risk factors patients with a catheter associated urinary tract infection were individually matched to control patients with a urinary catheter but without infection by age, gender, date and the hospital location of the infection in 1:2 fashion., Results: A total of 50 patients with catheter associated urinary tract infection were identified and matched to 100 control patients. Compared to controls the patients with infection were more likely to have a catheter in place for longer (2.9 days, OR 1.08, 95% CI 1.01, 1.15, p = 0.02). They were also more likely to be on contact precautions (OR 4.00, 95% CI 1.73, 9.26, p = 0.001), and have concurrent infections (OR 3.04, 95% CI 1.39, 6.28, p = 0.005) and a history of catheterization (OR 3.24, 95% CI 1.55, 6.77, p = 0.002). Using a conditional multivariate regression model the 3 most predictive variables were duration of catheter drainage, contact isolation status and history of catheterization., Conclusions: Longer duration of urinary catheter drainage, positive contact precautions status and a history of catheterization appear to be associated with a higher risk of catheter associated urinary tract infection in hospitalized pediatric patients. Physicians should attempt to decrease the duration of catheterization, especially in patients who meet these criteria, to minimize the risk of catheter associated urinary tract infection., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Little generalizable information is available on the outcomes of children diagnosed with bladder and bowel dysfunction (BBD) after a urinary tract infection (UTI). Our objectives were to describe the clinical characteristics of children with BBD and to examine the effects of BBD on patient outcomes in children with and without vesicoureteral reflux (VUR)., Methods: We combined data from 2 longitudinal studies (Randomized Intervention for Children With Vesicoureteral Reflux and Careful Urinary Tract Infection Evaluation) in which children <6 years of age with a first or second UTI were followed for 2 years. We compared outcomes for children with and without BBD, children with and without VUR, and children with VUR randomly assigned to prophylaxis or placebo. The outcomes examined were incidence of recurrent UTIs, renal scarring, surgical intervention, resolution of VUR, and treatment failure., Results: BBD was present at baseline in 54% of the 181 toilet-trained children included; 94% of children with BBD reported daytime wetting, withholding maneuvers, or constipation. In children not on antimicrobial prophylaxis, 51% of those with both BBD and VUR experienced recurrent UTIs, compared with 20% of those with VUR alone, 35% with BBD alone, and 32% with neither BBD nor VUR. BBD was not associated with any of the other outcomes investigated., Conclusions: Among toilet-trained children, those with both BBD and VUR are at higher risk of developing recurrent UTIs than children with isolated VUR or children with isolated BBD and, accordingly, exhibit the greatest benefit from antimicrobial prophylaxis., (Copyright © 2016 by the American Academy of Pediatrics.)

Introduction/objective: Modern radiographic advances have allowed for detailed and accurate imaging of not only urologic anatomy but also urologic function. The art of observational inference of subtle anatomic features and function from a static radiograph is being traded for new, more precise, and more expensive modalities. While the superiority of these methods cannot be denied, the total information provided in simpler tests should not be ignored. The relationship between high grade vesicoureteral reflux with the dilated calyces arranged cephalad to a dilated funnel-shaped renal pelvis on VCUG and reduced differential renal function has not been previously described, but has been anecdotally designated a "flowerpot" sign by our clinicians. We hypothesize that the appearance of a "flowerpot" kidney as described herein is an indicator of poor renal function in the setting of high grade VUR., Study Design: IRB approval was obtained and 315 patients were identified from system-wide VCUG reports from 2004-2012 with diagnosed "high grade" or "severe" vesicoureteral reflux. Inclusion into the study required grade IV or V VUR on initial VCUG and an initial radionuclide study for determination of differential function. Patients with a solitary kidney, posterior urethral valve, multicystic dysplastic kidney, renal ectopia, or duplex collecting systems were excluded. Grade of reflux, angle of the inferior-superior calyceal axis relative to the lumbar spine, and differential uptake were recorded along with presence of the new "flowerpot" sign. Variables were analyzed using the Mann-Whitney U test to determine statistical significance., Results: Fifty seven patients met inclusion criteria with 11 being designated as "flowerpot" kidneys. These "flowerpot" kidneys could be objectively differentiated from other kidneys with grade IV and/or grade V VUR both by inferior-superior calyceal axis (median angle, 52° [37-66] vs. 13° [2-37], respectively p < 0.001) and by differential renal uptake (median, 23% [5-49] vs. 45% [15-81], respectively p < 0.001). Likewise, there was no difference between either calyceal axis (median angle, 13° [3-20] vs. 13° [2-37]) or differential function (median, 48% [24-81] vs. 40% [15-66], p = 0.129) when comparing kidneys with grade IV and grade V VUR, respectively, that did not demonstrate the "flowerpot" sign., Discussion/conclusion: Grading of VUR is used to provide a common language for scientific discussion and determine prognosis for children with similar attributes. The dysmorphic calyceal system in the "flowerpot" kidneys supports the theory of abnormal renal blastema induction associated with abnormal differentiation of the ureteral bud. Even in the absence of urinary tract infections and/or pyelonephritis, renal abnormalities and decreased differential function can be observed on renal scintigraphy. This study also confirms the male predominance and functional similarities between grade 4 and 5 refluxing renal units. Recognizing this is a limited observational study based on imaging alone, the "flowerpot" sign is an indicator of the most severe form of grade 5 VUR but is only one factor in predicting long term overall renal prognosis. However, 14% (8/57) of our cohort had a relative uptake of less than 20% with 5 of these exhibiting the "flowerpot" sign. The "flowerpot" sign on VCUG can be used as indirect evidence of poor differential renal function and, therefore, useful in guiding parental expectations prior to formal functional imaging., (Copyright © 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: Radiographic evaluation for prenatal hydronephrosis often includes voiding cystourethrography to ascertain whether vesicoureteral reflux is present. We sought to determine whether use of voiding cystourethrography could be limited to those patients at greatest risk for vesicoureteral reflux. We hypothesized that vesicoureteral reflux could be predicted by findings on renal/bladder ultrasonography of hydroureter, renal dysmorphia and/or duplication., Materials and Methods: We reviewed the records of patients with prenatal hydronephrosis who underwent initial postnatal ultrasonography and voiding cystourethrography during a 3-year period. The presence of vesicoureteral reflux on voiding cystourethrogram was correlated to ultrasound findings, including hydronephrosis grade, presence of hydroureter, renal dysmorphia or duplication, with ultrasound considered positive for any of the latter 3 findings., Results: Of 262 patients 47 (18%) had vesicoureteral reflux. Ultrasound was positive in 24 of 29 patients (83%) with high grade reflux and 12 of 18 (67%) with low grade reflux. If ultrasonography showed any of the 3 positive findings, the odds ratio of detecting vesicoureteral reflux was 8.07 (95% CI 3.86, 16.87). Using these criteria, among all cases of prenatal hydronephrosis 5 (2%) with high grade vesicoureteral reflux and 6 (2%) with low grade reflux would have been missed. Among the 47 cases of reflux overall 5 of 29 high grade (17%) and 6 of 18 low grade cases (33%) would have been missed., Conclusions: By using ultrasonography criteria of hydroureter, duplication and renal dysmorphia for patients with prenatal hydronephrosis, vesicoureteral reflux can be detected more specifically. Using our criteria, 165 of 262 voiding cystourethrograms (63%) could have been avoided in patients with prenatal hydronephrosis during a 3-year period. Reducing these evaluations may decrease risks regarding radiation exposure, family anxiety and health care costs., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Children with febrile urinary tract infection commonly have vesicoureteral reflux. Because trial results have been limited and inconsistent, the use of antimicrobial prophylaxis to prevent recurrences in children with reflux remains controversial., Methods: In this 2-year, multisite, randomized, placebo-controlled trial involving 607 children with vesicoureteral reflux that was diagnosed after a first or second febrile or symptomatic urinary tract infection, we evaluated the efficacy of trimethoprim-sulfamethoxazole prophylaxis in preventing recurrences (primary outcome). Secondary outcomes were renal scarring, treatment failure (a composite of recurrences and scarring), and antimicrobial resistance., Results: Recurrent urinary tract infection developed in 39 of 302 children who received prophylaxis as compared with 72 of 305 children who received placebo (relative risk, 0.55; 95% confidence interval [CI], 0.38 to 0.78). Prophylaxis reduced the risk of recurrences by 50% (hazard ratio, 0.50; 95% CI, 0.34 to 0.74) and was particularly effective in children whose index infection was febrile (hazard ratio, 0.41; 95% CI, 0.26 to 0.64) and in those with baseline bladder and bowel dysfunction (hazard ratio, 0.21; 95% CI, 0.08 to 0.58). The occurrence of renal scarring did not differ significantly between the prophylaxis and placebo groups (11.9% and 10.2%, respectively). Among 87 children with a first recurrence caused by Escherichia coli, the proportion of isolates that were resistant to trimethoprim-sulfamethoxazole was 63% in the prophylaxis group and 19% in the placebo group., Conclusions: Among children with vesicoureteral reflux after urinary tract infection, antimicrobial prophylaxis was associated with a substantially reduced risk of recurrence but not of renal scarring. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; RIVUR ClinicalTrials.gov number, NCT00405704.).

Purpose: Dilating vesicoureteral reflux provokes concern for physicians and parents that often leads to corrective surgery in young children. Since there are limited data describing the natural history of dilating vesicoureteral reflux in infants, we identified factors predictive of resolution/improvement in infants initially treated nonoperatively., Materials and Methods: We reviewed the medical records of 90 infants 6 months old or younger from 2004 to 2010 who were referred for prenatal hydronephrosis or initial febrile urinary tract infection and found to have dilating vesicoureteral reflux (grade 3 or greater). Variables of interest included presentation, dimercapto-succinic acid results, sex, breakthrough febrile urinary tract infections, reflux grade and bilateral reflux. Cox regression analysis was performed to determine predictors of spontaneous resolution and/or improvement to reflux grade less than 3 as well as predictors of surgical intervention., Results: Included in final analysis were 80 infants (113 renal units). Of the patients 51 (64%) experienced spontaneous resolution/improvement with a mean followup of 29 months before resolution, discharge home and/or end of followup. Only 20 patients (25%) underwent surgery. Cox regression analysis revealed that a normal initial dimercapto-succinic acid scan, initial reflux grade less than 5 and absent breakthrough febrile urinary tract infections were predictive of reflux resolution/improvement (p <0.05). Dimercapto-succinic acid scan abnormalities, prenatal hydronephrosis and breakthrough febrile urinary tract infections were significant predictors of surgery (p <0.05)., Conclusions: Dilating vesicoureteral reflux in infancy often resolves/improves spontaneously. Therefore, surgery should be directed toward patients unlikely to experience resolution, ie those with an abnormal initial dimercapto-succinic acid scan, grade 5 vesicoureteral reflux and breakthrough febrile urinary tract infections., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

The upper urinary tract forms as a consequence of the reciprocal inductive signals between the metanephric mesenchyme and ureteric bud. A clue to the timing of events leading to an abnormality of the upper urinary tract can be the presence also of associated anomalies of internal genitalia since separation of these systems occurs at about the 10th week of gestation. Prenatal sonography has facilitated the detection of urological abnormalities presenting with hydronephrosis. Hydronephrosis suggests obstruction, but by itself cannot be equated with it. Instead, further radiographic imaging is required to delineate anatomy and function. Now, moreover, non-surgical management of CAKUT should be considered whenever possible. Despite the widespread use of prenatal screening sonography that usually identifies the majority of congenital anomalies of the urinary tract, many children still present with febrile urinary tract infection (UTI). Regardless of the etiology for the presentation, the goal of management is preservation of renal function through mitigation of the risk for recurrent UTI and/or obstruction. In the past many children underwent surgical repair aimed at normalization of the appearance of the urinary tract. Today, management has evolved such that in most cases surgical reconstruction is performed only after a period of observation - with or without urinary prophylaxis. The opinions presented in this section are not espoused by all pediatric urologists but represent instead the practice that has evolved at Children's National Medical Center (Washington DC) based significantly on information obtained by nuclear renography, in addition to sonography and contrast cystography.

Importance: A child's health, positive perceptions of the research team and consent process, and altruistic motives play significant roles in the decision-making process for parents who consent for their child to enroll in clinical research. This study identified that nonconsenting parents were better educated, had private insurance, showed lower levels of altruism, and less understanding of study design., Objective: To determine the factors associated with parental consent for their child's participation in a randomized, placebo-controlled trial., Design: Cross-sectional survey conducted from July 2008 to May 2011. The survey was an ancillary study to the Randomized Intervention for Children with VesicoUreteral Reflux Study., Setting: Seven children's hospitals participating in a randomized trial evaluating management of children with vesicoureteral reflux., Participants: Parents asked to provide consent for their child's participation in the randomized trial were invited to complete an anonymous online survey about factors influencing their decision. A total of 120 of the 271 (44%) invited completed the survey; 58 of 125 (46%) who had provided consent and 62 of 144 (43%) who had declined consent completed the survey., Main Outcomes and Measures: A 60-question survey examining child, parent, and study characteristics; parental perception of the study; understanding of the design; external influences; and decision-making process. RESULTS Having graduated from college and private health insurance were associated with a lower likelihood of providing consent. Parents who perceived the trial as having a low degree of risk, resulting in greater benefit to their child and other children, causing little interference with standard care, or exhibiting potential for enhanced care, or who perceived the researcher as professional were significantly more likely to consent to participate. Higher levels of understanding of the randomization process, blinding, and right to withdraw were significantly positively associated with consent to participate. CONCLUSIONS AND RELEVANCE Parents who declined consent had a relatively higher socioeconomic status, had more anxiety about their decision, and found it harder to make their decision compared with consenting parents, who had higher levels of trust and altruism, perceived the potential for enhanced care, reflected better understanding of randomization, and exhibited low decisional uncertainty. Consideration of the factors included in the conceptual model should enhance the quality of the informed consent process and improve participation in pediatric clinical trials.

Purpose: We analyzed preoperative and postoperative differential renal function and characterized the renographic findings in patients with ureteropelvic junction obstruction associated with Dietl crisis., Materials and Methods: Patients with Dietl crisis who underwent pyeloplasty between January 2004 and December 2010 were classified by renographic presentation. Patients in group 1 were diagnosed with cortical retention, those in group 2 had an initial obstructed scan (T1/2 of 20 minutes or more and no cortical retention) and those in group 3 had an initial nondiagnostic scan (T1/2 of less than 20 minutes and no cortical retention). Renographic parameters were used to analyze each group., Results: A total of 59 patients met criteria for study inclusion. The 13 patients in group 1 demonstrated the most significant recovery of function after pyeloplasty (mean differential renal function change 13.59%). The 38 patients in group 2 exhibited a mean differential renal function change of 43.06% (range 20% to 54.6%) and mean preoperative T1/2 of 64.31 minutes. Pyeloplasty was performed in all 8 patients in group 3 based on subsequent diagnostic scan (4 patients) or increased hydronephrosis on other imaging associated with further symptomatic episodes (4). Initial renographic patterns noted in group 3 included biphasic curves, diminished clearance after 15 minutes upright or symptoms despite nonobstructive drainage., Conclusions: Interpretation of diuretic renography requires the assimilation of multiple parameters since patients with Dietl crisis can exhibit variability in renographic patterns due to the intermittent nature of ureteropelvic junction obstruction. Cortical retention represents a specific and pathognomic finding of acute ureteropelvic junction obstruction. With appropriate evaluation of these parameters, obstruction can be reliably diagnosed and appropriate surgical candidates chosen., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Considering that there are few absolute indications for the timing and type of surgical correction of vesicoureteral reflux, we objectively measured parental choice in how the child's vesicoureteral reflux should be managed., Materials and Methods: We prospectively identified patients 0 to 18 years old with any grade of newly diagnosed vesicoureteral reflux. All races and genders were included, and non-English speakers were excluded from analysis. Parents were shown a video presented by a professional actor that objectively described vesicoureteral reflux and the 3 treatment modalities of antibiotic prophylaxis, open ureteral reimplantation and endoscopic treatment. Then they completed a questionnaire regarding their preference for initial management, and at hypothetical followup points of 18, 36 and 54 months. Consultation followed with the pediatric urologist who was blinded to the questionnaire results., Results: A total of 86 girls and 15 boys (150 refluxing units) were enrolled in the study. Mean patient age was 2.6 years old. Preferences for initial treatment were antibiotic prophylaxis in 36, endoscopic surgery in 26, open surgery in 11, unsure in 26 and no response in 2. Among those initially selecting antibiotic prophylaxis, after 18 months the preference was for endoscopic treatment, but after 36 and 54 months preferences trended toward open surgery. After consultation with the pediatric urologist 68 parents chose antibiotic prophylaxis., Conclusions: Our data show that antibiotic prophylaxis is preferred as the initial therapy for vesicoureteral reflux by 35.6% of parents. However, given persistent vesicoureteral reflux, preferences shifted toward surgery. With time the preference for open surgery increased and the preference for endoscopic surgery decreased., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: Ureteroceles are an infrequently seen and challenging pediatric urological condition that in addition to causing obstruction, may also be associated with vesicoureteral reflux and/or obstruction of the bladder outlet. Past experience with the morbidity associated with ureteroceles presenting with urinary tract infection may have stimulated a particularly aggressive approach as evidenced by more historical reports describing total reconstruction. This article purposes to review the recent literature in support of less aggressive management of ureteroceles in children., Recent Findings: The widespread availability and reported high success rates with endoscopic puncture of ureteroceles, along with the recognition that vesicoureteral reflux associated with ureteroceles can be effectively managed nonoperatively, has shifted the paradigm towards an individualized approach with greater emphasis placed on nonoperative management or less aggressive surgical techniques. Cystic renal dysplasia associated with ureterocele, much like that seen in isolation, is likely to involute thus providing spontaneous 'decompression' of the ureterocele and avoiding the need for surgery when it is present., Summary: Although total reconstruction of renal moieties associated with ureteroceles might be appealing as it can achieve a normal appearing urinary tract with a single procedure performed in infancy, a more individualized approach that relies on less aggressive surgical treatments and nonoperative management over time can achieve the same functional results.